Home Health Nursing: Mosby Items and Derived Items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 1

Home Health Nursing
Mosby items and derived items 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
Slide 1
Home Care
Bathroom
Kitchen
DME: Durable Medical
Equipment
Local pharmacy
911/you/ambulance
Steps
Visiting therapists
Home Health Nurse
Facility Care
Dirty Utility room
Clean utility room
CSR: Central Supply Room
24 hour in house pharmacy
Code Team/ ICU
Elevators
In house therapist
( PT/OT/Speech & gym)
Whole Nursing Team
IV Team
Respiratory Therapy Team 24/7
Slide 2
Home health nursing services enable individuals

of all ages to remain in the comfort and security
of their homes while receiving health care.
Family support, familiar surroundings, and
participation in the care process contribute to
feelings of worth and dignity.
Services may include skilled nursing, physical
therapy, speech language therapy, occupation
therapy, social services, intravenous therapy,
nutritional support, home health aide, respiratory
therapy, acquisition of medical supplies and
equipment, and homemaker and companion care.
Slide 3
Case
Manager
Supply
Acquisition
Transportation
coordination
Appointments
& School
Bathing, ADL, Personal Care
Nutritional
Needs
Slide 4
(From Potter, P.A., Perry, P.G. [1997]. Fundamentals of nursing: concepts, process, and practice. [4th ed.]. St.
Louis: Mosby.)
Educating the patient in the home setting.

Slide 5
Four Different Perspectives

Official
Services are provided to individuals and their
families in their place of residence for the purpose of
promoting, maintaining, or restoring health or of
minimizing the effects of illness and disability.
Patient
Skilled and compassionate care is provided on a oneto-one basis in the comforting and familiar
surroundings of the home.
Slide 6
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and
management of clinical problems. [6th ed.]. St. Louis: Mosby.)
In the home, the nurse encourages the patient to use imagery to relax
and relieve pain.
Slide 7
Four Different Perspectives (continued)

Family
It is a means to keep the family together as a
functioning, integrated unit.
Provider
All disciplines involved are challenged to provide
excellent care in often less-than-excellent conditions
and surroundings.
Slide 8
Advocacy
Nursing
Care
Physician
Home
Am care
ADL/ OOB
Transfers
Medications
administration
School
Feeds
GT/ oral
Travel
Wound care
TUBE CARE
Ostomy /Foley
Physician orders for

everything
Procurement
Acquisitions
Clean Supplies and

Equipment
Reorder/ restock
Medication
Administer
Reconcile
Call MD for reorders

Pharmacy Pick up
Call Pharmacy as needed.

Pick up meds PRN
Letters of medical
necessity Prescriptions
Physician
Communication
Relay for the family and
MD
Schedule appointments
Arrange
Transport
Supplies
Verbal Orders
Written transcribed and
signed off.
Slide 9
Home care was formerly defined as simply

providing physical care to the sick in their homes,
but the scope and complexity of the concept and
practice have grown.
Roots of the concept can be traced to the New
Testament of the Bible, which describes visiting the
sick as a form of charity.
The first home health care program in the United
States was organized in 1796 as the Boston
Dispensary.
The first visiting nurse service in the United States
was formed in Philadelphia in 1886.
Slide 10
Lillian Wald and Mary Brewster developed a

visiting nurse service for the poor in New York City
in 1893 at the Nurses Settlement House on Henry
Street.
In the 1800s and early 1900s, visiting nurse
associations were formalized, and public health
departments became widespread.
The Social Security Act of 1935 first provided
government rather than local charitable funding
for selected services such as maternal health,
communicable disease, and the training of public
health professionals.
Slide 11
When Medicare became effective in 1966, it

revolutionized home care by
Changing it to a medical rather than nursing
model of practice
Defining and limiting services for which it would
reimburse
Changing the payment source and even changing
the reason home care was provided
Slide 12
Diagnosis-Related Groups (DRGs)

Congress enacted this prospective payment
system in 1983 as a part of the Tax Equity and
Fiscal Responsibility Act for hospitals receiving
Medicare reimbursement.
Based on major diagnostic categories, a set rate
is paid for the hospitalized patient's care rather
than the cost or charges traditionally billed by
institutions.
Slide 13
Diagnosis-Related Groups (DRGs)

(continued)
The net effect of the change was a major shift of
patients out of the hospital into their homes,
extended-care facilities, or skilled nursing
facilities.
This created a challenge in terms of volumes of
patients seen, necessity of more skilled nursing
care over intensive times, and the evolution of
highly technical procedures in the home.
Slide 14
Agencies may have to comply with federal,

state, and local laws and regulations via the
following
Licensure by the state
Certification by the state certifying body designated
by the federal government
Certificate of need granted by some state according
to rules and formulas devised by state regulators
Accreditation by an outside agency that evaluates
how well the agency meets certain standards set by
the accrediting organization
Slide 15
Agencies Classified According to

Tax status: for profit or not for profit
Location: freestanding or institution-based
Governance: private or public
Slide 16
Seven Types of Home Care Agencies
Voluntary
Official
Combination
Hospital
Proprietary
Private not-for-profit
Other
Slide 17
JCAHO is looking for agencies to establish

ethics committees to handle issues that
arise in the home.
Psychiatric nurse clinicians are being
reimbursed by Medicare for home visits.
Social workers are taking a more active role
in home health care.
More home health agencies are employing
nurse pain specialists to assess and manage
pain control in the home.
Slide 18
Most agencies are obtaining a separate

Medicare certification to provide hospice
care.
Pet care programs are emerging to reduce
stress for the home health patient who is
too ill to care for his or her pet.
Electronic home visits may be evolving.
One of the most rapidly growing segments
in home health is home infusion therapy.
Slide 19
Skilled Nursing
This is provided and directed by currently licensed
registered nurses.
Basic nursing services may be provided by the
LPN/LVN under the supervision of the RN.
Service goals
Restorative, improvement, maintenance, promotion
Nurses practicing in the home setting must be

technically proficient, self-motivated, innovative,
and independent decision makers.
Slide 20
Role of the LPN/LVN

Skilled service has become a growing field of
practice for the LPN/LVN as agencies cope with
increased staffing needs, nursing shortages, and
recognition of the contributions the LPN/LVN can
make to home care.
Independent practice is not allowed, but selfdirection, motivation, creativity, clinical
proficiency, flexibility, compassion, empathy, and
patience are all essential attributes.
Slide 21
Physical Therapy
Services must be provided by a qualified and
licensed physical therapist.
A physical therapists assistant may deliver
limited services under the supervision of the
licensed therapist.
The goals of treatment must be restorative for
Medicare reimbursement but may be
maintenance or preventive for other payer
sources.
Slide 22
Speech-Language Therapy
Speech services must be provided by a mastersprepared clinician who has been certified by the
American Speech and Hearing Association.
Therapy goals include minimizing communication
disorders and their physical, emotional, and social
impact.
Independent functioning and maximum
rehabilitation of speech and language abilities are
primary treatment goals.
Slide 23
Occupation Therapy
Services deal with lifes practical tasks.
The therapist will choose and teach therapeutic
activities designed to restore functional levels.
Services include
Techniques to increase independence
Design, fabrication, and fitting of orthotic or self-help
devices
Assessment for vocational training
Slide 24
Medical Social Services

Services are provided by social workers prepared
at the masters level.
Focus is on the emotional and social aspects of
illness.
The care plan includes education, counseling,
payment source identification, and referrals.
Slide 25
Homemaker-Home Health Aide

The aide provides the basic support services that
can enable an elderly individual, disabled adult, or
dependent child to remain at home.
Most aid services fall into one of three categories
Personal care
Physical assistance
Household chores
Slide 26
Referral
Entry point into the home health care system
Can come from the patient, family, social service
agency, hospital, physician, or another agency
Slide 27
Admission
The initial evaluation and admission visits are
made by an RN within 24 to 48 hours of the
referral.
The evaluation and admission process generally
includes at least the following.
Complete patient evaluation
Environmental assessment
Identification of primary functional impairments
Assessment of the family or significant other support
system
Determination of knowledge and adherence to
treatments and medications
Slide 28
Admission (continued)
Evaluation and admission process (continued)
Determination of desire for care and services
Involvement of the patient and family in the
development of the plan of care and goals
Notification to the patient of rights as a patient, along
with costs, payment sources, and billing practices
Explanation of the patients right to selfdetermination
Provision of initial nursing interventions
Slide 29
Care Plan
The physician must be contacted for specific
orders before delivery of care.
A treatment plan is drafted cooperatively with the
physician.
The plan describes the current physical status of
he patient, medications, treatments, the
disciplines needed to provide care, the frequency
and duration of services, the goals/outcomes, and
the time frame for implementation.
It must be signed by the physician and serves as
the traditional physical orders.
Slide 30
Visits
Visits for interventions by ordered disciplines are
made to meet the patient-centered goals and
progress toward identified outcomes.
Patients may be visited as infrequently as once a
month to several times a day; several visits per
week are typical.
Slide 31
Documentation
Concise and complete documentation is essential.
It may be hand-written, dictated, or entered into a
computer.
Many agencies are beginning to use various
problem classification schemes linked with nursing
diagnoses, specific interventions, and defined
patient outcomes.
It provides an accurate picture of the type and
quality of care and reflects the effectiveness of
the plan of care and progress toward goals and
outcomes or the reason for lack of progress.
Slide 32
Discharge Planning
Planning begins with admission.
When patient goals or other specific criteria are
met, the discharge occurs.
The purpose of discharge planning is to promote
continuity of care in the patients home.
Slide 33
This provides documentation for outside

organizations and for internal measures of
improvements and refinements of policies and
procedures.
Three major elements
Structural criteria
Process criteria
Outcome criteria
Quality assessment plans reflect standards,

objectives, and measurable outcomes and
include plans for remediation or improvement
as an integral part of the process.
Slide 34
Slide 35
Slide 36
Slide 37
Medicare
This federal program requires agencies to be
certified as meeting the federal conditions of
participation, which set forth specific
requirements for organization, staffing, training,
types of services covered, and agency evaluation.
Beneficiaries of services must be 65 or older,
disabled, or have end-stage renal disease.
Must be under the care of a licensed physician,
homebound, and in need of skilled nursing therapy
services
Slide 38
Medicaid
This pays for home care services to indigent and
low-income people of all ages.
It is administered by the state but is both state
and federally subsidized.
Services vary from state to state, but most include
the basic services covered by Medicare plus
expansion of aide and personal care services.
Slide 39
Third Party
Limited home care services are paid for.
Coverage, requirements, and payment rates vary.
Reimbursement is often tied to post
hospitalization recoveries.
A case manager will determine and arrange for a
mix of home care, therapy services, counseling,
supplies, and equipment for a patient.
Slide 40
Private Pay
Individuals may also pay directly for home health
services. Charges may be the standard full
charge or may be scaled down based on ability of
the patient to pay.
Other Sources
Health maintenance organizations (HMOs) and
preferred provider organizations (PPOs) have
negotiated contracts with home health agencies
to provide services to their patients.
Both are prepaid health plans operated
independently or through employer groups.
Slide 41
Nurses encounter great diversity in a variety of

cultural interactions.
Culture is present in the lives of patients, families,
and health care providers and is especially
apparent in the home environment.
Nurses need to anticipate potential cultural
problems and identify their own and others values.
Cultural health practices may be incorporated into
traditional medical care in the home environment,
provided it does not conflict with the prescribed
treatment.
Slide 42
Nursing Diagnoses
Interrupted family process

Impaired parenting
Anxiety
Caregiver role strain
Impaired physical mobility
Imbalanced nutrition, less than body
requirements
Disturbed thought processes
Ineffective airway clearance
Risk for impaired skin integrity
Slide 43
Nursing Diagnoses (continued)
Family coping, compromised

Family coping, disabled
Coping, ineffective
Ineffective management of therapeutic regimen
Knowledge, deficient
Risk for caregiver role strain
Risk for injury
Slide 44
The NO no List
DO not use white out.
Do Not Cross out or scribble.
DO not write error
NO Transcription of numbers or
letter
( tracing over to change a
number is not allowed)
X X
error
strode
k
X X
Slide 45
Current trends support the growth of home care

as an economical, humane, preferred health
delivery system for many types of care.
Home care provides needed assessment and
evaluation of chronic illnesses to prevent acute
episodes.
Aides and homemakers can provide necessary
support in activities of daily living to enable the
patient to remain in the home.
Skilled nursing and therapy offer rehabilitation
and prevention of deterioration, as well as
methods to cope with physical changes.
Slide 46
Home health care allows individuals to

maintain personal control and to participate in
the direction of their personal care.
Families are an important part of the success
of home care services as home care workers
provide care, supervision, assistance, and
support in attaining the care plan goals.
Home health care is not a new concept;
however, legislative, regulatory, and current
health care trends have changed the way it is
provided.
Slide 47
A number of different professional and

paraprofessionals disciplines provide home
care services based on coordinated plan of
care of approved by a physician. Teamwork is
an essential component of the concept.
Home health agencies are organized groups
that employ or contract with professionals
and paraprofessionals to provide services.
Different types of agencies may be subject to
varying federal, state, and local laws and
regulations.
Slide 48
Skilled nursing care is the most frequently

provided services. RNs and LPNs/LVNs under
the supervision of the RNs provide direct care
of different levels of complexity.
Providers of care in the home must possess
special qualities to effectively practice in this
nontraditional environment.
Home health care agencies strive to provide
the highest quality of services economically.
Success is evaluated through quality
assurance plans.
Slide 49
Home health services are reimbursed by

federal, state, local, group, and private
sources.
Although some aspects of nursing
interventions in the home are the same as
those practiced in other health care setting,
home health care nurses pay particular
attention to interaction and cooperation
among family members, the patient, and
other members of the health care team.
Slide 50
The acuity levels of patients requiring care

in their homes continues to rise, and the
technological equipment, including use of
mechanical equipment and invasive
procedures such as intravenous therapies,
are increasing in home care. These factors,
when combined with shorter hospital stays,
require extensive discharge planning to
prepare patients and family for home health
care.
Slide 51
Slide 52
Slide 53
Slide 54
Slide 55
HOW
MANY
VISIT
S?
Slide 56
Slide 57
Assess the home upon admission and routinely for Safety Factors, problems and needs:
Assess the clients home for Safety issues.
Body Mechanics for client and Staff
Is the clients bed safe is it a good height for the client and nurse
Bathroom safety: Bars , commode lifer, non slip surface mats
Kitchen Safety: safe stove , pot handles in, burners working
Are extension cords safe or a fire hazard ( frayed, worn, over loaded)
Does the client have a working phone
Does the client have electric and running water
Are smoke and fire distinguishers present
Are the medications stored separately, with in dates and not expired, out of
reach of small children and elderly
Are floors clear of clutter, throw rugs to prevent falls and tripping accidents
Lifting safety? Is the client able to walk, transfer or do they require a lift.
Ramps and house access for disabled
Abuse Risk assessments elderly, small children and disabled
Slide 58
Electrical plug covers

Stove handle covers, pot handles inward
Medicine safety lids and out of reach
Poison control hot line # present
Bed rails or crib rails, gates up
Tub safety, never leave unattended
Water temp checked prior to bath
Slide 59
Nurses give report and get report

Please indicate who you picked up the client from and
how you received report
Please document whom you left the client in care of
.There is a box for this on the flow sheet at the bottom.
Family or client must sign flow sheet at the end of shift.
Samples:
1) Baby Billy was received in the care of mom. Mom States Baby Billy had a good day with O2 sats at 98%.
2) Jimmy Joe was received from Nurse Nancy. Verbal report given.
3) Karen resting in bed, side rails up, no apparent distress noted.
4) Suzie Q was left in care of Uncle Sam and resting comfortably in bed.
Slide 60
All equipment should be cleaned and maintained.

Sanitation of equipment is done by wiping down equipment
daily and then soaking equipment for 20 minutes once a
week in a
10 % solution of vinegar and water.

(1oz vinegar to 10 oz water)
Submerge items in solution for specified length of time 15-20

minutes twice week.
Remove disinfected items from basin and rinse in water.
Air dry or dry with paper towels before storing.
Store in clean, dry, dust-free environment, e.g., plastic, ziploc bag,
or lidded jar
.
. Discard solutions into toilet, wash basin with soap and water,
rinse and dry with paper towels.
Slide 61
Know patient code status, living will etc.

Respect family wishes
Full code- initiate CPR and call 911
If the DNR (signed by MD ) is NOT in writing, it is a FULL code no
matter what the family wishes are.
NO CODE support and respect client
Post mortem care per family wishes
WHO TO NOTIFY:
911; Client Physician; HHA Office, Direct Supervisor; Director of Nursing.
Slide 62

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Home Health Nursing: Mosby Items and Derived Items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 1

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Home Health Nursing

Home health nursing services enable individuals

Bathing, ADL, Personal Care

Educating the patient in the home setting.

Four Different Perspectives

Four Different Perspectives (continued)

Physician orders for

Clean Supplies and

Call MD for reorders

Call Pharmacy as needed.

Home care was formerly defined as simply

Lillian Wald and Mary Brewster developed a

When Medicare became effective in 1966, it

Diagnosis-Related Groups (DRGs)

Diagnosis-Related Groups (DRGs)

Agencies may have to comply with federal,

Agencies Classified According to

Seven Types of Home Care Agencies

JCAHO is looking for agencies to establish

Most agencies are obtaining a separate

Nurses practicing in the home setting must be

Role of the LPN/LVN

Medical Social Services

Homemaker-Home Health Aide

This provides documentation for outside

Quality assessment plans reflect standards,

Nurses encounter great diversity in a variety of

Interrupted family process

Nursing Diagnoses (continued)

Family coping, compromised

Current trends support the growth of home care

Home health care allows individuals to

A number of different professional and

Skilled nursing care is the most frequently

Home health services are reimbursed by

The acuity levels of patients requiring care

Electrical plug covers

Nurses give report and get report

3) Karen resting in bed, side rails up, no apparent distress noted.

All equipment should be cleaned and maintained.

10 % solution of vinegar and water.

Submerge items in solution for specified length of time 15-20

Know patient code status, living will etc.

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